World Journal of Clinical Surgery
Laparotomy in Children in a Tertiary Hospital in a Developing Country:
Indications, Complications and Outcome
Chukwubuike Kevin Emeka
Institutional affiliations
Pediatric Surgery Unit, Department of Surgery, Enugu State
University Teaching Hospital, Enugu, Nigeria.
Corresponding author
Chukwubuike Kevin Emeka
Department of Surgery, Enugu State University Teaching Hospital,
Enugu, Nigeria.
e-mail: chukwubuikeonline@yahoo.com
Article Type: Research Article
Received Date: Oct 20, 2021
Accepted Date: Oct 22, 2021
Published Date: Nov 23, 2021
Abstract
Background: Pediatric laparotomy is important surgical
procedure necessary for the diagnosis and treatment of abdominal
surgical conditions in children. The objective of this study was
to evaluate our experience on pediatric laparotomy in terms of
indications, complications and outcome. Methodology: This was
a retrospective study of children aged 15 years and younger who
had laparotomy (for various indications) between January 2017
and December 2018 at the pediatric surgery unit of Enugu State
University Teaching Hospital (ESUTH) Enugu, Nigeria. Results:
A total of 202 pediatric laparotomies were performed during the
study period. There was male predominance and the median age of
the patients was 5 years. Majority of the patients were infants and
most of the laparotomies were performed as emergency surgeries.
The mean duration of hospital stay of the patients was 10 days and
abdominal pain was the most common symptom. At presentation,
one-half and one-quarter of the patients had low hemoglobin and
electrolyte derangement respectively. Abdominal ultrasound and x
rays were diagnostic in about 50% of the patients. Intussusception
was the most common indication for laparotomy and surgical site
infection was the most common post-operative complication.
Eleven (5.4%) patients expired. Conclusion: Laparotomy in
children can be lifesaving and infants with intussusception were
the largest group of patients in the current series. Abdominal pain,
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anemia and electrolyte derangement were the common indices
at presentation. Pediatric laparotomy can be associated with
morbidity and mortality.
Keywords: Children, complications, developing country,
indications, outcome.
1. Introduction
Laparotomy, also known as celiotomy, is a surgical procedure that
involves making incision through the anterior abdominal wall
to gain access into the abdominal cavity. Historically, in 1809,
Ephraim McDowell performed the first successful laparotomy
without anesthesia. In 1881, George Goodfellow treated gunshot to
the abdomen through a laparotomy.1 Laparotomy may be classified
into diagnostic laparotomy or therapeutic laparotomy. In diagnostic
laparotomy, which is also known as exploratory laparotomy, the
nature of the pathology is not known and laparotomy is required to
confirm the pathology. In therapeutic laparotomy, the pathology has
been identified and laparotomy is required for the treatment of the
pathology. Exploratory laparotomy may continue as a therapeutic
procedure.2 In children, the indications for laparotomy ranges
from congenital to acquired anomalies. The congenital anomalies
that require laparotomy include intestinal atresia while acquired
anomalies such as intussusception is also treated via laparotomy.
Other indications for laparotomy in children include severe
abdominal trauma, abdominal malignancy and gastrointestinal
bleeding.3 Although laparotomy is lifesaving, complications may
occur and the outcome is in low income countries is still far from
what is obtainable from developed countries.4 There is paucity of
data on pediatric laparotomy in Nigeria, hence, the need for this
study. The objective of this study was to evaluate our experience
on pediatric laparotomy in terms of indications, complications and
outcome.
2. Materials and Methods
This was a retrospective study of children aged 15 years and
younger who had laparotomy (for various indications) between
January 2017 and December 2018 at the pediatric surgery unit
of Enugu State University Teaching Hospital (ESUTH) Enugu,
Nigeria. ESUTH is a tertiary hospital located in Enugu, South
East Nigeria. The hospital serves the whole of Enugu State,
which according to the 2016 estimates of the National Population
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Commission and Nigerian National Bureau of Statistics, has a 3.2. Presenting symptoms
population of about 4 million people and a population density of Abdominal pain was the most common symptom in the patients.
616.0/km2. The hospital also receives referrals from its neighboring Other symptoms are shown in Table 2.
states. Patients who have had laparotomy at a peripheral hospital
before referral to ESUTH for reoperation were not excluded Presenting symptoms Number of patients (%)
from the study. Patients with incomplete medical records and Abdominal pain 177 (87.6)
those older than 15 years of age were excluded. Information was
Vomiting 151 (74.8)
extracted from case notes, operation notes, operation register, and
Constipation 98 (48.5)
admission-discharge records. The information extracted included
age, gender, nature of the laparotomy, interval between onset of Abdominal distension 53 (26.2)
symptoms and presentation, interval between presentation and Non-specific symptoms 12 (5.9)
laparotomy, presenting symptoms, investigations performed,
intra-operative finding, operative procedure performed, post Table 2: Presenting symptoms of the patients
laparotomy complications, duration of hospital stay and outcome
of treatment. All the laparotomies were performed by a consultant
pediatric surgeon. Ethical approval was obtained from the ethics 3.3. Investigations
and research committee of ESUTH. Statistical Package for Social 3.3.1. Hematological and biochemical
Science (SPSS) version 21, manufactured by IBM Cooperation Ninety-eight (48.5%) patients had a hemoglobin level of less than
Chicago Illinois, was used for data entry and analysis. Data were 10 grams per deciliter (g/dl) whereas 57 (28.2%) patients had
expressed as percentage, median, mean and range. electrolyte derangements.
3.3.2. Imaging
3. Results All the patients had plain abdominal radiograph and abdominal
3.1. Patients demographics ultrasound. Abdominal radiographs were diagnostic in 95 (47.0%)
A total of 217 pediatric laparotomies were performed during the patients whereas ultrasound was diagnostic in 121 (60%) patients.
study period but only 202 cases had complete record and formed Computed tomography (CT) scan was performed in 17 (8.4%)
the basis of this report. Details of the demographics are shown in patients. Magnetic resonance imaging (MRI) was not performed
Table 1. in any of the patients because of non-availability. Upper
gastrointestinal contrast study was done in 15 (7.4%) patients
Gender
while 13 (6.4%) patients had barium enema.
Male 141 (69.8) 3.4. Intra-operative findings (indications) and operative
Female 61 (30.2%) procedure performed
Age range 7 days to 14 years The intra-operative findings and definitive operations performed
(median 5 years) are shown in Table 3.
Age groups
Neonates (< 1 month) 21 (10.4%)
Infants (1-12 months) 108 (53.5%)
12 months to 15 years 73 (36.1%)
Nature of the laparotomy
Emergency 171 (84.7%)
Elective 31 (15.3%)
Mean interval from symptom onset to 5 days (2-14 days)
presentation
Median interval from presentation to 2 days (1-4 days)
laparotomy
Mean duration of hospital stay 10.2 days(range 7-18)
Table 1: Demographic profile of the patients

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gastrointestinal tract may be in the form of intestinal obstruction

Operative finding Number of Operative procedure
patients (%) or perforation peritonitis.7

Intussusception 97 (48.0)
In the present study, there was male predominance. This finding
Non-viable bowel 65 (32.2) RHC + ITA is consistent with the report of other authors.8, 9 The reason for the
gender difference is not known. The age range of our patients is at
Viable bowel 32 (15.8) Manual reduction
variance with the report of Ghritiaharey et al.8 The age at pediatric
Typhoid intestinal 55 (27.2) Closure of perforation laparotomy varies widely and may depend on the pathology
perforation
involved. For instance, intussusception is more likely to occur in
Ruptured appendix 11 (5.4) Appendectomy + infants while typhoid intestinal perforation is more likely to occur
drainage
in older children. About 50% of the patients in the current series
Adhesive intestinal 11 (5.4) Adhesiolysis were infants. However, one study from Pradesh, India reported
obstruction
that majority of their patients who had laparotomy were between
Intestinal atresia 7 (3.5) Resection + anastomosis 5 years and 12 years of age.8 The pathological condition, its
etiology, time of onset of symptoms and age at presentation of the
Ruptured omphalocele 7 (3.5) Closure + repair
patients may determine the age at laparotomy. There were more
Gastroschisis 6 (3) Closure + repair emergency laparotomies than elective laparotomies in the index
Ruptured spleen 6 (3) Splenectomy study. Negussie et al also reported more emergency laparotomies
in their series.10 The mean period of 5 days before presentation to
Strangulated external 2 (1) Resection + anastomosis
hernia the hospital may reflect the high level of poverty and ignorance
that is prevalent in low income countries. The mean interval of 2
days between presentation and laparotomy was the time required
Table 3: Operative finding and treatment rendered
for investigation and optimization of the patients for surgery. Our
RHC=Right hemicolectomy; ITA=Ileotransverse anastomosis
patients stayed for an average of 10 days. Following laparotomy,
the length of time patients stay in the hospital may depend on
3.5. Post laparotomy complications
the extent of the operative procedure performed and the post-
One hundred and eighty-one (89.6%) patients did not have any
operative course.
complications. Twenty-one (10.4%) patients developed at least
one complication: Surgical site infection 10 (5%); enterocutaneous
Abdominal pain is a common complaint in children and the
fistula resulting from anastomotic leak 4 (2%); adhesive intestinal
challenge lies in differentiating surgical from non-surgical causes.11
obstruction 3 (1.5%); incisional hernia 2 (1%); burst abdomen 2
Abdominal pain was the most common symptom of the patients in
(1%).
the current series. Chukwubuike in his series on intussusception
also reported abdominal pain as a common presentation in
3.6. Outcome of treatment
children that required laparotomy.12 Older children vocalize their
One hundred and ninety-one (94.6%) patients made a full recovery
abdominal pain while infants may express abdominal pain by
and were discharged home. Eleven (5.4%) patients expired. Ten
drawing the knees to their chest when they cry.13 The origin of
out of the 11 patients that died were neonates. The cause of death
the abdominal pain could be visceral, somatic or referred. Other
was overwhelming sepsis. One infant died from respiratory failure
presenting symptoms may depend on the pathology and time of
secondary to aspiration pneumonitis.
presentation. For instance, children presenting late with typhoid
intestinal perforation may have abdominal distension in addition
4. Discussion
to abdominal pain. Non-specific symptoms such as weight loss and
Surgical needs of children are fundamentally different from those
dyspepsia may be seen in children with intestinal malrotation.14
of adults. Congenital anomalies and surgical conditions resulting
from infective processes form a large portion of the overall surgical
About half of our patients had a hemoglobin level of less than
burden in children.5, 6 Acute abdominal conditions in children may
10 g/dl on presentation. The low hemoglobin level may be pre-
be caused by a variety of pathological conditions that require
existing or may have followed the onset of symptoms. Children in
surgical management. The pathological conditions affecting the

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World Journal of Clinical Surgery
low income countries are prone to anemia due to poor nutritional
status and parasitic infestations such as helminthiasis.15 Sepsis
and passage of red currant jelly stool may also explain the low
hemoglobin level. Electrolyte derangements such as hyponatremia
and hypokalemia were noticed in about one-quarter of our patients.
Delayed presentation of the patients with the associated prolonged
vomiting and spurious diarrhea may explain the electrolyte
derangement. All the patients had abdominal ultrasound and
plain abdominal x ray. However, these investigations were
only diagnostic in about 50% of the patients. The expertise and
experience of the radiologist may determine the ability of the
radiologist to detect the offending pathology. Only one-tenth of our
patients had a CT scan. The non-availability, non-affordability and
the risk of radiation exposure associated with CT scan accounted
for low number of children that had CT scan. A few patients had
contrast studies (upper and lower intestinal series). The request
for contrast studies was based on findings on clinical evaluation.
In the current study, the most common indication for laparotomy
in children was intussusception. One study from North central
Nigeria also found intussusception as the most common pediatric
abdominal surgical emergency requiring laparotomy.16 However,
Ekenze et al and Abatanga et al in their separate studies reported
typhoid intestinal perforation as the most common indication for
laparotomy17, 18 This difference in findings may be explained by the
difference in the age cohort of children recruited by the different
studies. For instance, Abatanga et al recruited only children who
are older than one year of age18 The indications for laparotomy
in children may vary from place to place and from time to time.19
The majority of our patients did not develop any complications.
Surgical site infection was the most common complication in the
current study. Other series also reported surgical site infection as a
common complication.20, 21 Enterocutaneous fistula is an unpleasant
complication of operations on the gastrointestinal tract. Four
(2%) of our patients that developed enterocutaneous fistula were
managed non-operatively and the fistula healed on non-operative
treatment. Adhesive intestinal obstruction may result from fibrous
bands and adhesions formed during the healing process. Technical
factors (surgeon’s factor) and/or patient’s factors may result in
inadequate healing culminating into a burst abdomen or incisional
hernia.
Majority of our patients survived. Most mortality was among
neonates who succumbed to overwhelming sepsis. Ekenze et al
in their series also reported that there was higher mortality in
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neonates who underwent laparotomy.17 Neonates are unique group
of individuals that have different features from older children and
adults. The fragile homeostasis of neonates may be tipped over by
the stress of surgery, anesthesia, and sepsis.22
5. Conclusion
Laparotomy in children can be lifesaving and infants with
intussusception were the largest group of patients that had
laparotomy in the current series. Abdominal pain, anemia and
electrolyte derangement were the common indices at presentation.
Pediatric laparotomy can be associated with morbidity and
mortality. We recommend early presentation, prompt diagnosis
and treatment of pediatric abdominal surgical conditions to reduce
the sequelae experienced in pediatric laparotomy.
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